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| Medical Guidelines | Reason for Update |
|---|---|
| Adaptive Behavioral Treatment for Autism Spectrum Disorders | Added the following statement to When Covered Section: “There is an established DSM-5 diagnosis of Autism Spectrum Disorder diagnosed by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism. Medical Director review 8/2022. Notification given 9/13/2022 for effective date 11/15/2022. |
| Breast Surgeries | Section V Surgical Management of Breast Implants description updated. Section V When Covered section updated to include the following statement: “Removal of breast implants with capsulectomy/capsulotomy is considered medically necessary when the following criteria has been met (See Policy Guidelines): Baker Class III contractures (only if the initial implant was for reconstructive purposes), Baker Class IV contracture.” And “Removal of a breast implant and capsulectomy is covered, regardless of the indication for the initial implant placement, for: Treatment of Anaplastic Lymphoma of the breast when there is pathologic confirmation of the diagnosis by cytology or biopsy; or Individuals with an increased risk of implant-associated Anaplastic Lymphoma of the breast due to use of Allergan BIOCELL textured breast implants and tissue expanders.” Section V When not Covered section updated to include the following statement: “Removal of breast implants with capsulectomy/capsulotomy is not covered for Baker Class III contractures in patients with implants for cosmetic purposes.” Section V Policy Guidelines Updated to include Baker Classification System. Added codes 19370 and 19371 to Section V Billing/Coding Section, References updated. Medical Director Review 8/2022. Specialty Matched Consultant Advisory Panel review 8/2022. Notification given 9/13/2022 for effective date 11/15/2022. |
| Coronavirus Testing in the Outpatient Setting | New policy developed. BCBSNC will provide coverage for Coronavirus Testing in the Outpatient Setting when medical criteria and guidelines outlined in the policy are met. Medical Director review 7/2022. Notification give 9/13/2022 for effective date 11/15/2022. |
| Gender Affirmation Surgery and Hormone Therapy | Codes 15876 and 15877 moved from noncovered to covered in Billing/Coding section per management review. |
| Genetic Testing for Mental Health Disorders | New policy developed. Genetic Testing for Mental Health Disorders is considered investigational for all applications. BCBSNC does not provide coverage for investigational services or procedures. Medical Director review 7/2022. Notification given 9/13/2022 for effective date 11/15/2022. |
| Leadless Cardiac Pacemakers | Description, including Regulatory Status, References and Policy Guidelines sections updated. Added statement to Not Covered section: “The Aveir™ single-chamber transcatheter pacing system is considered investigational for all indications.” Specialty Matched Consultant Advisory Panel review 10/2022. Medical Director review 10/2022. |
| Surgery for Obstructive Sleep Apnea and Upper Airway Resistance Syndrome | Specialty Matched Consultant Advisory Panel review 8/17/2022. |
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